Microsoft word - botox new patient info-

ALLEN AESTHETICS & LASER CENTER
Name: ________________________________Date of birth:______________________________ Street address: _________________________ City: ___________ State: _______ Zip: _______ Telephone: (home) ___________________ (work) _______________ (cell) ________________ Email Address: _________________________________________________________________ How were you referred here: ______________________________________________________ Previous treatments: Yes/No Date last treated: __________ Area treated: ________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ PATIENT’S NAME:________________________AGE:______Date___/___/___ Are you currently under the care of a physician for your skin? If yes, why?______________________________________ Have you ever seen a dermatologist or other physician for your skin? If yes, when and why?_______________________________ Have you previously had: Chemical Peel? Y Type of Peel_________________Date_______ Laser Resurfacing, Dermabrasion, Phototherapy or Microdermabrasion? Y Type/Depth________Date_______ Facial Surgery? Procedure:___________________Date_________ Have you ever done any aggressive exfoliation to your skin in the last 2 weeks? Y If yes, explain:________________________________________________________ What skincare products do you use frequently?__________________________________ Are you taking AccutaneR? What topical medicateions do you use or have used? Have you ever used a topical fluorouracil preparation on your skin? If yes, when?__________________On what area of your body?_____________________ Other:(this includes topical antibiotics, OTC acne remedies, Hydrocortisone, etc.) Please list any oral medications you currently take:_____________________________________________________________________________________________________________________________________________________________________ (this includes hormones, birth control pills, antibiotics, tranquilizers, anti-depressants, diuretics, etc.) Please list any nutritional supplements you take:________________________________ HYPERSENSITIVITY AND SKIN FRAGILITY: Have you ever had a skin allergy or sensitivity? (rash, irritation, peeling, swelling, hives, etc) Do you have any known allergies to anything? Y If yes, please list all allergies: (this includes medications, aspirin, food, etc.) Do you “flush” or “appear reddened” easily when you eat spicy food, drink alcohol, get angry, go in the sun, etc.? Y How much?_________________________________________ How much?_________________________________________ List any dietary concerns:________________________________ How much?_______________Type:______________________ Multi-Vitamins:________________Antioxidants:_____________ How many glasses per day?______________________________ FOR WOMEN ONLY: Do you have regular periods? If yes, during pregnancy did you ever experience hyperpigmentation or a “pregnancy mask?” PIGMENTATION (Fitzpatrick Scale): How do you tan? What is your Ethnicity and Race (heritage)?_________________________________________________________ VASCULARITY (telangiectasia or broken capillaries): Nose area ACNE: Do you have any history of acne or periodic breakouts? Do you only experience breakouts during or around your menstrual cycle? Do you always have a pimple or some type of breakout? If yes, date of last treatment:_________________ SKIN TYPE: Does your skin ever flake or feel tight and dry? Is your skin ever shiny a few hours after cleansing? Frequently Occasionally How often do you experience blackheads or blemishes? Frequently ABILITY TO HEAL: Does your skin appear fragile or burn easily? If yes, explain:___________________________ Do you have any problems healing from a cut or burn? Y If yes, explain:___________________________ If yes, explain:___________________________ Do you ever use depilatories or waxes on your face? If yes, explain:___________________________ If yes, explain:___________________________ In the past (including childhood) did you live in a sun belt? In the past have you neglected to use a sunscreen when outdoors? Do you currently wear a sun protection product all day, everyday? Are you willing to wear a sun protection product all day, everyday? Have you or any member of your family had skin cancer? If yes, Who?__________________________Anatomical location of the lesion(s): ARE YOU CURRENTLY SEEING A PHYSICIAN FOR ANY REASON? Y IF YES, PLEASE EXPLAIN____________________________________________________________________ HOW DO YOU WANT TO IMPROVE YOUR SKIN? 1)__________________________________ 2)__________________________________ SKIN What specific areas do you want to treat? PATIENT SIGNATURE__________________________________________________DATE_______________________ TECHNICIAN SIGNATURE________________________________________DATE______________________________ Aspirin and aspirin-related products (see following list) should not be taken either 7- 10 days before or 7-10 after surgery because they increase the tendency of bleeding. For this reason, it is very important that contents of any “over-the-counter prepara- tions” be checked carefully prior to their use. Many headache preparations, cold remedies, and “hangover cures” contain ASPIRIN. The chemical name of aspirin is Examples of drugs containing salicylates (aspirin) are as follows: Examples of aspirin-related products are as follows: You can substitute TYLENOL (acetaminophen) for these products if you require pain medication before surgery. Check with your pharmacist if you are uncertain whether a medicine contains aspirin. Herbal Medications & Nutritional Supplements Some herbal medications and nutritional supplements may also increase bleeding or photosensitivity (i.e., sun sensitivity). Please discontinue all herbal medications and nutritional supplements 7-10 days before and 7-10 days after procedure. Some of the following plant foods, such as celery, dill, fennel, may be used in moderation in your Some herbal medications that may make you bleed: If you are taking a routine multi-vitamin, you may continue doing so. However, if you are taking any vitamin E pills, please stop 10 days before and 10 days after procedure, as this may increase your chance of bleeding.

Source: http://www.allenaestheticsandlasercenter.com/forms/PatientPacket-InjectableProcedures.pdf